[Hiring] Utilization Review Nurse @WVU Medicine

Role Description

Responsible for working in collaboration with the Medical Director on driving the decrease in care variance, to ensure timely discharges, and to refer members to other plan resources to meet their care conditions. Reports to the Health Plan Manager of Utilization Management. This position will be an integral member of the health plan’s medical management team.

Qualifications

• Current Registered Nurse license issued by the state in which services will be provided or current multi-state Registered Nurse license through the enhanced Nurse Licensure Compact (eNLC).
• Three (3) years of healthcare clinical experience.
• Bachelor's Degree in Nursing OR Associate of Science in Nursing Degree (ASN); Currently enrolled in a BSN program and BSN completion within three (3) years of hire.
• Medical Management for Medicare and/or Medicaid populations.
• Utilization Management experience.

Requirements

• Assists with the build and implements care management review processes (Prior Authorization, Predetermination, Concurrent Reviews, Retrospective Reviews) that are consistent with established industry and corporate standards.
• Assists with the build and implements all care management reviews according to accepted and established criteria, as well as other clinical guidelines and policies.
• Ensures that interventions are collaborative and focus on maximizing the member’s health care outcomes.
• Understands the Peer-to-Peer Review process and works with the Medical Directors to continuously improve member and Provider Network services for this process.
• Educates internal and external stakeholders and partners to continuously improve processes and build network relationships.
• Works collaboratively with other members of the medical management team to identify members whose healthcare outcomes may be enhanced by coaching and/or case management interventions.
• Understands the data that is collected within the position, and works with other team members on improving outcomes.
• Commits to a career of life-long learning and continuous improvement of processes that span the realm of Utilization Management.

Benefits

• This role may require occasional weekend and holiday work.
• Scheduled Weekly Hours: 40
• Shift: Exempt/Non-Exempt: United States of America (Exempt)

Company Description

Company: PHH Peak Health Holdings

Cost Center: 2403 PHH Medical Management